Anesthesia Coding Alert

Reader Question:

Submit 00902 for Prostate Massage Under MAC

Question: A patient presented for an exam under anesthesia with prostate massage. The anesthesiologist administered MAC. His notes state, "With relaxation was able the palpate his entire prostate. I then perform prostate massage bilaterally. Prostate had no palpable masses." I keep going back and forth between 00902 and 01999. What should I report?

Vermont Subscriber

Answer: If the anesthesiologist performed the procedure from a rectal approach, your best option is 00902 (Anesthesia for; anorectal procedure). This is an unusual procedure so you might need to discuss it with the anesthesiologist before finalizing the claim.